Vulvodynia What a Health Practitioner Should Know

Transcription

1 Vulvodynia What a Health Practitioner Should Know Catherine M. Leclair, MD Associate Professor Director, Program in Vulvar Health Objective: To present a clinically based approach to vulvodynia Identify and review vulvar anatomy Basic understanding of how to approach the patient with vulvar complaints Recognize vulvodynia as part of the differential diagnosis in women with vulvovaginal concerns No disclosures Mons Labia majora Labia minora Clitoral Hood Clitoris Urethra Hymen Vestibule Vaginal opening Bartholin meatus Posterior fourchette Perineum (Anus) 1

2 Mons Clitoris Labia majora Labia minora Vestibule next to hymen Perineum Definition of Vulovodynia Definition: vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurologic disorder Considered a neuropathic condition 2

3 Clarification of terms by ISSVD ISSVD Classification Vulvodynia-spectrum of conditions Generalized versus Localized Provoked versus Unprovoked Replace term Vulvar Vestibulitis Syndrome with Vestibulodynia or Provoked Localized Vulvodynia Replace Essential Vulvodynia or Dysesthetic Vulvodynia with Generalized Unprovoked Vulvodynia Vulvodynia: A spectrum of conditions Generalized Unprovoked Vulvodynia Vestibulodynia (vulvar vestibulitis) Clitorodynia Mixed Vulvodynia Prevalence 8-15% of the general population likely single leading cause of dyspareunia.. 3

4 Office Evaluation: History Quality: onset, frequency, provoked or unprovoked, location, severity, circumstances, description of pain Exposure to contact irritants: soaps, spermicide, lubricants, bathing products or intra-vaginal products Vulvar Hair Hygiene: shave, laser, wax Hormonal status : Estrogen replete vs depleted (postpartum, menopause, anti-estrogen breast cancer treatment) Skin changes: associated symptoms of itching, ulceration, fissures or skin breakdown OTC or other treatments tried Office Evaluation: Tools Physical Exam Visual inspection of vulva, perineum, anus & vagina (speculum) Qtiptest Microscopy: swab side walls/fornix not cervix ph immediately (normal estrogen replete vagina ) NaCl and KOH: sensitivity ~70% Vaginal Culture: vaginal side walls or fornix, not cervix Fungal culture helpful for identification of yeast species General bacterial culture not helpful AFFRIM for common vaginitis (>90% sensitive) Vulvar Biopsy: Reserved only for SKIN CHANGES Random biopsy not helpful What s in your Differential Diagnosis? Hypoestrogenism (Vulvovaginal Atrophy) Lichen sclerosus Lichen planus Lichen simplex chronicus Vaginismus or Levator myalgia Chronic Yeast vulvovaginitis Interstitial cystitis Herpes simplex Contact Dermatitis DIV: Desquamative Inflammatory Vaginitis 4

5 Vulvodynia is a diagnosis of exclusion Common Types of Vulvodynia Vestibulodynia (Localized Provoked) Generalized Unprovoked Case Presentation: Vestibulodynia 28yo G0 on OCPs presents with dyspareunia. She complains of a raw sensation with penetration and redness at her vaginal opening. 5

6 Vestibulodynia SYMPTOMS Entry dyspareunia Difficult tampon use Painful speculum exam Pain usually only with touch and not constant SIGNS -/+Vestibular erythema + Qtiptest Response to lidocaine Difficult speculum exam Vestibulodynia or Localized Provoked Vulodynia: Diagnosis Friedrich s Triad Reported painful penetration Qtiptest positive for tenderness -/+ vestibular erythema *** if vestibular erythema is present with no other sites of vulvar erythema or skin changes, then likelihood of a vulvar dermatosisis extremely low 6

7 Qtip Test Gently roll moist Qtip Vestibule clockface 12, 2, 4, 6, 8, 10 o clock Score 0-3+ Case Presentation: Generalized Unprovoked Vulvodynia 58yo woman on HRT who complains of constant vulvar burning and irritation. Generalized Unprovoked Vulvodynia Symptoms Burning pain Searing pain Usually non-focal and constant Sensation may with activity/manipulation Lidocaine provides no relief Signs No physical exam finding (other than vulvovaginal atrophy) 7

8 Vulvodynia Treatment Overview: all types Hygiene & Vulvar Care Measures Topical neuromodulators and medicines Oral neuromodulators Physical therapy + Biofeedback for Vestibulodynia Sexual Counseling Surgery: Vestibulectomy for Vestibulodynia Reduce Vulvar Irritants Use of scented products, dyes, or chemicals Tight, synthetic, or uncomfortable clothing Vulvar hair removal Daily use of mini-pads Encourage bland emollients for soothing effect (Vaseline or plain Crisco ) Cold packs and Sitz baths offer palliation Topical Neuromodulators 2% lidocaine gel or 4% liquid for use with sex prn 5% lidocaine cream TID or ointment on cotton ball at vestibule QHS 2% amitriptyline-baclofen cream TID 2-6% gabapentin cream TID SHOW WHERE TO APPLY Up to 6-12 wkstreatment before reduced pain 8

9 Oral neuromodulators TCAs: amitriptyline (Elavil ), nortriptyline, desipramine GABA meds: gabapentin (Neurontin ), pregabalin (Lyrica ) SNRI: duloxetine (Cymbalta ), venlafaxine (Effexor ) Other anticonvulsants Oral Neuromodulators Clear data in generalized vulvodyniabut less in vestibulodynia Most of the studies looking at oral meds mix generalized and localized in one study Many advocate use of neuromodulators since etiology seems to be based in change in nervous system function (central + local) Vestibulodynia Vestibule surface pain Poor sexual confidence & identity Levator myalgia 9

10 Vulvodynia Treatment Overview Hygiene & Vulvar Care Measures Topical neuromodulators and medicines Oral neuromodulators Physical therapy + Biofeedback Sexual Counseling Surgery: Vestibulectomy Vestibulodynia: Surgical Treatment Most studied treatment Expect % improvement Multiple studies supporting with f/u 6mon-5 yrs Surgical outcome improved when paired with PT Before and after procedure Modified versus Total Vestibulectomy 10

11 Treatment for Vestibulodynia: What can you do? Validate the pain and diagnosis Offer lidocaine for sex Apply 10-15min to vestibule prior Coach around good lubricants and adequate arousal Consider referral: vulvar specialist, sexual counseling, and/or PT (Local vulvar program here in Oregon) Treatment for Generalized Vulvodynia: What can you do? Validate pain and diagnosis Consider oral neuromodulators Coach around vulvar care measures Consider referral to vulvar specialist In summary Vulvodynia should be considered in women with vulvovaginal complaints Vulvodynia is common (8-15%) but a diagnosis of exclusion PE often without findings, bx not helpful Can offer lidocaine for palliation with sex Neuromodulators the mainstay Consider the paradigm for vestibulodynia to include a multi-disciplinary approach 11

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